Provider Demographics
NPI:1124286521
Name:PHYSICIANS INSTITUTE FOR PAIN MANAGEMENT, LLC
Entity type:Organization
Organization Name:PHYSICIANS INSTITUTE FOR PAIN MANAGEMENT, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:HARRISON
Authorized Official - Last Name:CAMPAGNA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:229-247-3300
Mailing Address - Street 1:2418 N OAK ST
Mailing Address - Street 2:SUITE B 1
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31602-2576
Mailing Address - Country:US
Mailing Address - Phone:229-247-3300
Mailing Address - Fax:229-247-1131
Practice Address - Street 1:2418 N OAK ST
Practice Address - Street 2:SUITE B 1
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602-2576
Practice Address - Country:US
Practice Address - Phone:229-247-3300
Practice Address - Fax:229-247-1131
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-02
Last Update Date:2008-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA033806174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000046358BMedicaid
GA000046358BMedicaid